Reducing care time after implementing protocols for acute ischemic stroke: a systematic review

Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.

Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.

Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.

Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.

Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.

Factors Affecting Pre-Hospital and In-Hospital Delays in Treatment of Ischemic Stroke; a Prospective Cohort Study

Introducion:

The outcomes of acute ischemic stroke (AIS) are highly affected by time-to-treatment. The present study aimed to determine the factors affecting in-hospital and pre-hospital delays in treatmentof AIS.

Methods:

This prospective study was carried out on 204 AIS patients referring to the stroke care unit in Zanjan (Iran) in 2019. The required data were collected by interviewing the patients and families and using patients’ records and observations.

Results:

The maximum delay was related to onset-to-arrival time (288.19 ± 339.02 minutes). The logistic regression analysis indicated a statistically significant decline in the treatment delay via consultation after the initiation of symptoms (p< 0.001), transferring the patient through emergency medical service to the hospital (p<0.001), and patients’ perception regarding AIS symptoms (P< 0.001).

Conclusion:

It is essential to inform people regarding AIS symptoms and referring to AIS treatment units to reduce the treatment time.

Regional Intervention of Stroke Care to Increase Thrombolytic Therapy for Acute Ischemic Stroke

Background and Purpose- The aims of this study were to investigate the effect of an intervention to unblind data on r-tPA (recombinant tissue-type plasminogen activator) administration and sharing data with chief executive officers of participating hospitals, on r-tPA administration rates postintervention and on potential healthcare cost savings implemented at 26 Southeast Texas Regional Advisory Council hospitals. Methods- Retrospective analysis of prospective data on thrombolytic therapy from 26 Southeast Texas Regional Advisory Council hospitals, collected between April 2014 and June 2016. The control (blinded) period (Q2-2014 to Q2-2015) was followed by unblinding (Q3-2015). Results- Intervention was associated with 21.1% increase in r-tPA administration rates, with 38.5% increase in r-tPA administration with door-to-needle time ≤60 minutes. An absolute increase in r-tPA administration of 2.1% was seen with an average lifetime cost savings of $3.6 million. Conclusions- Transparent regional data sharing was associated with improved r-tPA administration and healthcare cost savings.

Prehospital notification can effectively reduce in-hospital delay for thrombolysis in acute stroke

Aim: To reduce in-hospital intervals by developing a prehospital notification (PHN) protocol which directly notifies a neurologist to prepare for possible treatment. Methods: A 24/7 connection was established between emergency medical services dispatch and the on-call neurologist. A database of all patients with in-hospital stroke code activation was developed, door-to-computed tomography (CT) time and door-to-needle time was recorded from January 2013 to December 2016. The statistical results were considered significant at p < 0.05. Result: PHN resulted in a significant reduction in door-to-CT time (median 14 vs 20; p < 0.001). Among patients who were treated with intravenous thrombolysis, door-to-needle time was significantly shorter in patients with PHN compared with non-PHN group (median 42 vs 70; p < 0.001). Conclusion: PHN effectively reduced door-to-CT and door-to-needle times.